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CarotidArteryStentingUnderNeuroprotectionDeviceCarotidarterystenosisAtheroscleroticplaqueformationatcarotidbifurcationPlaqueulceration,thrombusformation,anddistalembolismisthemajormechanismcausingsymptomsCarotidstenting(CS)hasbeenreportedsince1987asanalternativetoendarterectomyHowever,unprotectedCScarries5-10%riskofproceduralstrokePaulHLKaoProceduralembolismThemostcommonmechanismforproceduralstrokeEmbolicmaterialscanbereleasedinallstepsduringCSinalmosteverycaseParticlesobstructingcriticalvesselsresultinsymptoms,butmayalsobesilentwithunknownlong-termeffectEmbolicprotectiondevice(EPD)maythereforebemandatoryinCSPaulHLKaoSymptomaticrightICASPaulHLKaoSymptomaticrightICASLeftarmweaknessduringprocedurePlainCT3hrpoststentingPlainCT2dayspoststentingPaulHLKaoIdealprotectiondeviceCompleteinterceptionoftheemboliMaintaincerebralperfusionGoodhandlingcharacteristicsIntuitiveandcompatiblewithexistingprocedureandequipmentNosizinglimitationSafeandeffectiveinclinicalstudiesBut,IDEALEPDisnon-existingintherealworldPaulHLKaoPartiallistofcurrentEPDProximalocclusionInvatecMoMAArteriAPAESVelocimedProxisDistalocclusionMedtronic/PercuSurgeGuardWirePlusKenseyNashTriActivRubiconMedicalGuardianMeshfilterMedtronic/AVEMDTInterceptorMicrovenaTRAPEv3SPIDERSupportedmembranefilterAbott/Mednova

EmboshieldCordisAngioguardXPGuidantAccunetSCIONSCIProUnsupportedmembranefilterBSCFilterWireEX/EZMetamorphicE-Sack/E-TrapIntraTherapeuticsSulzer-IntraguardRubiconFilterPaulHLKaoDistalocclusionBalloon-tippedwirecrosseslesionInflationbeforeangioplastytostopanterogradeflowDebrisreleasedstayedinthestagnantcolumnofbloodAspirationtoremovedebrisPaulHLKaoAdvantageanddrawbackBettercrossingprofilethanotherdistaldevicesOnesizefitsall(3-6mm)EmbolicparticlesizeirrelevantLesionhastobecrossedfirstPatienttoleranceTimepressureontheoperatorPotentialdistalICAtraumaDistalfilterFiltercrossesthelesionFilterdeployedbeforeangioplastyAnterogradeflowmaintainedwhiledebrisreleasedstoppedbythefilterFinalretrievalofthefilterwiththetrappeddebrisPaulHLKaoAdvantageanddrawbackAnterogradeICAflowusuallymaintainedwithbetterpatienttoleranceLesstimepressureontheoperatorContrastcontrolispossibleforlesionvisualizationLesionhastobecrossedfirstBulkierandmorerigidincrossingtightandtortuousstenosisPotentialdistalICAtraumaEmbolicparticlessmallerthanporesizeescapefiltrationProximalocclusionOcclusionoftheCCAbeforelesionmanipulationAnterogradeflowstoppedordeminishedFurtherocclusionoftheECAmaybedonetocreatetotalflowterminationDebrisreleasedduringinterventionmayberemovedbyaspirationorartificialretrogradeflowPaulHLKaoAdvantageanddrawbackProtectionstartsbeforeICAlesionistouchedVirtuallynosizelimitonthetargetICAChoiceofanywire,balloon,andstentLargegroinaccessPatienttoleranceTimepressureontheoperatorPaulHLKaoPercuSurgeGuardWirePlussystemGuardWiretemporaryocclusionwireMicrosealportEZ-flatorinflationdeviceExportaspirationcatheterPaulHLKaoLICAstentingwithGuardWirePlusPaulHLKaoAngioguardXPNitinolfilterbasketwithsiliconmembrane(poresize100micron)DeliverysheathRetrievalsheathPaulHLKaoRICAstentingwithAngioguardXPPaulHLKaoRICAstentingwithAngioguardXPAngioguardXPPaulHLKaoFilterWireEXFishnetpolyurethanefiltermembrane(poresize80micron)withNitinolmouthloopSamemonorailsheathfordeliveryandcapturePaulHLKaoRICAstentingwithFilterWireEXPaulHLKaoRICAstentingwithFilterWireEXPaulHLKaoRICAstentingwithFilterWireEXPaulHLKaoEmboshieldSpecial0.014”wirewithdistal0.018”segmentFloatingfilterwithpolyurethanefiltermembrane(poresize150micron)andnitinolbasketframworkDeliverysheathCapturesheathPaulHLKaoLICAstentingwithEmboshieldPaulHLKaoLICAstentingwithEmboshieldPaulHLKaoMoMA10Frballoon-neckedcatheterforCCAocclusionExtensionballoonforECAocclusionCatheterlumenservesasworkingchannelforregularstentingequipmentsPaulHLKaoLICAstentingwithMoMAPaulHLKaoLICAstentingwithMoMAPaulHLKaoLICAstentingwithMoMAPaulHLKaoNTUHexperience-demographicsNon-protected(n=174)Protected(n=108)Sex,M/F123/5183/25Age,y72±874±8HTN,%7184DM,%2831HLP,%4448Smoking,%4655Symptomatic,%6566NASCETexclusion,%7067CCAdiameter,mm7.5±1.27.3±1.0ICAdiameter,mm5.4±0.85.4±0.8Lesionlength,mm21±920±7DS,%86±1090±7FinalRS,%13±812±7PaulHLKaoNTUHexperience-clinicalNon-protected(n=174)Protected(n=108)Tech.success,%100100Proceduralstroke/death,%4.61.9

Ipsi.stroke,%3.40.9Totalstroke,%4.01.9Death,%0.60Follow-up,m37±1217±11F/urate,%9899Newstroke/death,%6.90.9

Ipsi.Stroke,%2.90.9Totalstroke,%4.00Death,%3.40Angio.restenosis,%2.91.9PaulHLKaoNTUHcriteriaforEPDchoiceDistalballoonProximalballoonFilterIsolatedICA+++Contr.occlusion-/+-/++DiseasedCCA+-/++LargeICA>6-8mm-/++-Stringsign-/++-InsufficientWillis-/+-/++Longtortuouslesion-/++-Brachialapproach+-+PaulHLKaoConclusionProceduralembolism,maybeclinicallysilent,isuniversalinCSActiveembolicprotectioncanbeeffectiveachievedbyvariousdevicesInterventionistmustunderstanddevicedesignsandcharacteristicstofacilitateequipmentchoiceLackingdirectcomparisonbetweenCSwithorwithoutprotection,theaccumulatingclinicalevidencesuggestthatuseofprotectionshouldbethestandardpracticePaulHLKaoThankYouForYourAttentionEvidencesforproceduralembolismJ.Theronreported600-1300microncholesterolcrystalsin17of21samplescollectedduringCST.Ohkireportedparticlesfrom50to>1000micronreleasedinallstepsofCSusinghumancarotidplaquespecimenW.Jordanshowedaveraging74embolidetectedbyTCDduringCSprocedureK.Mathiasshowednewclinicalsilentsignal-intenselesionsbyMRIin28.5%ofunprotectedCSM.HenryinaPercuSurgeaspirateanalysisreportedparticlesinallCSproceduresPaulHLKaoPreventionofembolismPassiveAdjuvantpharmacologyRefinedproceduraltechniqueDedicateddevicesdesignedforCSActiveEmbolicprotectiondevicesPaulHLKaoTerminologyandclassificationPaulHLKaoPaulHLKaoPaulHLKaoComparisonofdifferentdevicesDistalLesionhastobecrossedfirstSmallerdeviceprofileOcclusionPerfusionistemporarilyStoppedCompleteinterceptionofdebrisProximalProtectionstartedbeforecrossinglesionLargevascularaccessinevitableFilterPerfusionmaintainedParticlessmallerthanporesizeescapedPaulHLKaoComparisonofdifferentdevicesproximalocclusiondistalocclusionfilterCrossingprofile++++++/-Visualization+/--++Tolerance+/-+/-++Re